Latrodectism following Black Widow envenomation is rare in Canada. We present the case of a previously healthy 50 year old male who presented with an acute abdomen, hypertension, and urinary retention. After a thorough work up it was determined to be as a result of a Black Widow spider bite. Due to climate change we may see more cases of Latrodectism in the future and it should be considered as a differential diagnosis in anyone presenting with an acute abdomen after an insect bite.

Introduction: Treat and Release (T&R) patients are seen and discharged home from the emergency department (ED), and asked to return within 12-72 hours for follow-up care (e.g., ultrasound, repeat blood work). Our two academic teaching hospitals see approximately 2,000 T&R patients per year. Handover of care for T&R patientsdone through charting only and therefore dependent on the charts adequacy and completenessis crucial to the safety and quality of care they receive. An 18-month retrospective chart audit at our sites identified quality gaps, including suboptimal documentation that ultimately impedes patient disposition. Our projects aim was to reduce the time-to-disposition (TTD; time spent by patients between provider initial assessment and discharge from the ED) by a third (from 70min) in 6-months time (March 2017), a target felt to be both meaningful and realistic by our stakeholder team. Methods: Our primary outcome measure was the TTD (in minutes). Our process measure was the quality of documentation, using a modified version of QNOTE, a validated tool used to assess the quality of health-care documentation. PDSA cycles included: 1) Involvement of stakeholders for the creation and refinement of an improved T&R handover tool to cue more specific documentation; 2) Education of health-care providers (HCPs) about T&R patients; 3) Replacement of the previous T&R handover tool with a newly designed and mandatory tool (i.e. a forcing function); 4) Refinement of the process for T&R patients and chart hold-over. Results: Run charts for both the median TTD and median modified QNOTE scores over time demonstrate a shift (i.e., run chart rule) associated with the second and third clustered PDSA cycles. After the first three clusters of PDSA cycles (i.e., before-and-after), mean TTD was reduced by 40% (70min to 42min, p=0.005). The quality of documentation (mean modified QNOTE scores) was also significantly improved (all results p<0.0001): patient assessment from 81% to 92%, plan of care from 58% to 85% and follow-up plan from 67% to 90%. Conclusion: We reduced the time-to-disposition for T&R patients by identifying gaps in the quality of documentation of their chart. Using iterative PDSA cycles, we improved their time-to-disposition through improved communication between health-care providers and a new T&R handover tool working as a forcing function. Other centers could use similar assessment methods and interventions to improve the care of T&R patients.

Editor’s note: CJEM has partnered with a small group of selected journals of international emergency medicine societies to share from each a highlighted research study, as selected monthly by their editors. Our goals are to increase awareness of our readership to research developments in the international emergency medicine literature, promote collaboration among the selected international emergency medicine journals, and support the improvement of emergency medicine world-wide, as described in the WAME statement at http://www.wame.org/about/policy-statements#Promoting%20Global%20Health. Abstracts are reproduced as published in the respective participating journals and are not peer reviewed or edited by CJEM.

Intentional insulin overdose may lead to severe and refractory hypoglycemia. Exogenous dextrose administration is the mainstay of therapy for these patients and is effective in most cases. However, in patients with a functional pancreas, exogenous dextrose administration may precipitate endogenous insulin release leading to rebound hypoglycemia. We describe a case report of a 41-year-old woman who injected 300 units of insulin aspart with suicidal intent. Her initial blood glucose was 2.3 mmol/L (41 mg/dL). Over the next 12 hours, she experienced recurrent hypoglycemic episodes despite 10% dextrose infusions and 14 ampoules of 50% dextrose. Our patient experienced complications, including peripheral edema, related to the large volumes of intravenous dextrose required to attempt to maintain euglycemia. Octreotide, a somatostatin analogue, may help prevent dextrose-induced hypoglycemia and improve the management in select insulin overdose patients; large infusion volumes resulted in significant peripheral edema. Treatment with octreotide was initiated 12.5 hours post-injection and was followed by a stabilization of blood glucose concentration in this non-diabetic patient.

Introduction: Over 1 million patients with head injuries (HIs) are seen every year at emergency departments (EDs) in North America, with over 90% being minor HIs. Over-utilization of computed tomography (CT) scans in these patients results in unnecessary exposure to radiation and increases health-care resource utilization. Using recommendations from the Choosing Wisely Campaign (CWC) and quality improvement (QI) methodology, we developed a local initiative targeting this issue. Our aim was to reduce the CT scan rate for patients presenting with HIs by 10% over a 6-month period at two academic EDs. This was considered both achievable and meaningful by our stakeholders. Methods: Baseline CT scan rates for patients with HIs were determined through a 10-month retrospective cohort review. We used stakeholder engagement and provider surveys to develop our driver diagram and PDSA cycles, which included: 1) Assessing and improving provider knowledge about the CWC recommendations; 2) Testing, refining and implementing a modified Canadian CT Head Rule checklist in the ED; 3) Developing and giving patients CWC-themed handouts pertaining to HI best practice; 4) Bimonthly reporting of CT scan rates to providers. Our primary outcome measure was the number of CT scans performed for patients with HIs. Process measures included the number of checklists completed and ED length of stay (LOS). Our balance measure was return ED visits within 72 hours. Results: Baseline rate of CT scans prior to our interventions was 47.9%. Our QI initiative resulted in a significant shift in the run chart of the weekly CT scan rates, associated with the second PDSA cycle cluster. We observed a 16% relative decrease in CT scans at 3 months (47.9% to 40.5%, P=0.005) and 10.4% at 8 months (47.9% to 43.1%, P=0.02). Non-sustained trends and shifts were seen in the run chart of median ED LOS for HI patients, but overall before-and-after median times were not significantly different (237min to 225min, P=0.18). 33% of total checklists were completed. 72-hr return visits did not change during the 8-month study period (4.0% to 4.16%, P=0.85). Conclusion: Our local QI initiative was successful in decreasing CT rates for patients presenting with a HI. The decrease in effect at 8 months suggests the need for continued feedback and reminders to ensure long-term sustainability. Other centres could use similar QI methods, as well as the materials we developed, to achieve similar results of improved evidence-based utilization of diagnostic tests.

Introduction: There is a high risk for communication breakdown, discontinuity of clinical care, and medical errors during ED physician handover. Locally, there is no standardized handover process to ensure adequate communication of critical information. Our aim was to use a locally developed handover tool to increase frequency of adequate physician handover during overnight shift change by 50% in 4 months. Methods: Using published best practices, local observational data, and stakeholder input, we determined critical components of ED handovers. We developed a structured communication tool for two unique populations in our ED: ED-VITAL for patients receiving active ED care; ED-VSA for patients who are admitted/referred. Strategies used to implement the tool included: engagement of staff physicians to introduce & modify the tool; formal education and training to ED residents; and provision of cognitive aids. A QI coordinator conducted direct observations of handovers using convenience sampling. We provided feedback to staff and resident physicians, and used their input to continuously modify the tool. The main outcome measure was adequate patient handover, defined as verbal communication of 50% of critical handover components, or documentation of key information on an electronic note. Process measures included tool utilization characteristics. Balance measures included time metrics such as handover duration. We present run charts and qualitative statistics. Results: We assessed 368 individual patient handovers (93 pre- & 275 post-implementation). The median proportion of patients in active ED care who were verbally handed over increased from 75% to 100%. The median proportion of adequate handovers improved from 50% to 72%. The time to deliver handover increased by 13 seconds per patient. Qualitative feedback from end users was positive overall, particularly for communication quality and resident educational value. Conclusion: Use of a standardized handover tool improved both verbal and documented communication during shift change. A customized approach, sensitive to local context, was important to successful implementation. Residents play a large role in handovers; strategies to improve handover processes that emphasize medical education appear to enhance success. Future PDSA cycles will focus on interventions to further enhance the utilization of the tool, and to measure direct impact on clinical outcomes.

Introduction: CT scan is the most common imaging modality for suspected renal colic and is used for about 80% of presentations. Cumulative ionizing radiation exposure from repeat CT scans increases long-term cancer risk. Despite a 10-fold increase in CT use to detect kidney stones in the ED in just over a decade, there has been no increase in the proportion of kidney stones diagnosed, number of significant alternate diagnoses or admissions to hospital. Choosing Wisely recommends to avoid ordering CT of the abdomen/pelvis in otherwise healthy patients<age 50 presenting to the ED with known history of kidney stones and with symptoms consistent with uncomplicated renal colic. The aim is that >90% of patients < age 50 with a history of renal stones arriving in Sunnybrook ED with symptoms consistent with renal colic will be managed without a CT abdomen/pelvis. Methods: Emergency physicians were engaged in the process at various stages, including a brainstorming session to perform a root cause analysis. A Driver diagram was created to generate change ideas. Outcome Measure Number of CT scans ordered for target population (Results: Results to date indicate that there is a non-sustained decrease in the number of CT scans performed on ED patients < age 50 with recurrent renal colic. The STONE score was infrequently used, thus making it difficult to standardize CT ordering for presumed renal colic. Conclusion: As a result of this QI initiative, there is awareness amongst emergency physicians of a patient population that is over imaged with CT scan, often with no change in management. Introduction of a low dose CT scan order was the greatest gain from this QI initiative. In order to decrease CT utilization, physicians need to be shown the lack of benefit of CT use and a safe alternative diagnostic approach.